What is the best approach for fluid resuscitation?

Fluid Resuscitation Protocol

Isotonic saline (0.9% sodium chloride) should be the first-choice fluid for initial resuscitation in patients with hypovolemia. 1

Initial Fluid Selection and Administration

• Crystalloids are the fluid of choice for initial resuscitation, with balanced crystalloids generally preferred over normal saline to reduce the risk of hyperchloremic metabolic acidosis 2, 3
• For septic patients, administer at least 30 mL/kg of crystalloid within the first 3 hours 1, 2
• For non-septic patients, use a fluid challenge technique with boluses of 250-1000 mL administered rapidly and repeatedly 3
• The initial fluid volume should be 10-20 mL/kg, with repeated doses based on individual clinical response 1

Assessment of Response and Targets

• Reassess the patient's hemodynamic status after each fluid bolus, evaluating:
  • Heart rate, blood pressure, respiratory rate
  • Skin perfusion, capillary refill time
  • Urine output (target >0.5 mL/kg/hr)
  • Mental status
  • Serum lactate levels (aim for 20% reduction if elevated) 3
• Use dynamic measures of fluid responsiveness rather than static measures like CVP alone 2

When to Stop Fluid Administration

• Stop fluid administration when:
  • No improvement in tissue perfusion occurs
  • Signs of fluid overload develop (pulmonary crackles, increased jugular venous pressure)
  • Hemodynamic parameters stabilize 2, 3

Special Considerations

• For patients requiring large volumes of fluid (e.g., in sepsis), synthetic colloids may be considered due to their longer duration in circulation, though evidence does not show superiority to crystalloids 1
• For elderly patients or those with cardiac dysfunction, consider smaller boluses (250-500 mL) with more frequent reassessment 3
• In patients with chronic kidney disease, carefully monitor for fluid overload as renal excretion of excess fluid is impaired 2
• Consider earlier initiation of vasopressors (norepinephrine as first choice) if the patient remains hypotensive despite initial fluid resuscitation 2, 3

Common Pitfalls and Caveats

• Delayed resuscitation increases mortality; immediate fluid resuscitation is required despite concerns about organ function 2
• Colloids are much more expensive than crystalloids (albumin costs around 140 Euro/L, HES 25 Euro/L, isotonic saline 1.5 Euro/L) 1
• Colloids carry potential infection hazards and risk of anaphylactic reactions 1
• Hydroxyethyl starches should be avoided due to increased risk of acute kidney injury and mortality, especially in patients with pre-existing kidney disease 2
• Hypotonic solutions are contraindicated in patients with (impending) cerebral edema 4